1. Optimizing Meds – Need for Systems Approach
An estimated 32% of adverse events leading to hospitalization are attributed to medications.
Patients with chronic conditions are able to adhere to their prescribed medication regimens only 33% to 50% of the time².
Medicare patient with multiple chronic conditions
Visits 13 healthcare providers and fills 50 prescriptions every year¹
The Patient- Centered Medical Home-Integrating comprehensive medication management to optimize patient outcomes. Available at
2, Smith M, Bates DW, Bodenheimer T, Cleary P. Why pharmacists belong in the medical home. Health Affairs 2010; 29(5):

2. The Medication Optimization Opportunity

3. Enhancing Primary Care Practice through Comprehensive Medication Management
Stage 1: Establishing Shared Philosophy and Decision to Invest and Improve
Aim 1: Baseline Assessment; Philosophy
Stage 2: Establishing the Patient Care Process
Aim 2: Best Practices in Design & Delivery of CMM
Stage 3: Building the Practice Management System to Support CMM
Aim 3: System-level and Structural Elements to Support Effective & Efficient Delivery of CMM
Collect patient information
Assess the patient and their medication-related needs
Develop and document the care plan
Implement the care plan
Provide follow-up
Pharmacist-provider communications
Pharmacist-patient communications
Standards and systems for documentation of patient encounters in the EMR
Triage and care coordination processes
Practitioner credentialing
Predictive analytics/patient risk stratification
Data integration systems supporting evaluation of return on investment and value
Quality measurement and reporting within the practice
Quality assurance and continuous practitioner development programs
Tools to support practitioner & practice efficiency
Payer relations, billing & data exchange systems
Stage 4: Demonstrating the Value of CMM toward Achieving the Triple AIM
Aim 4: Key Performance Measures and Effectiveness
Improved Health
(Clinical & Operational Measures)
Improved Patient & Provider Experience (Satisfaction Measures)
Lower Per Capita Cost
(Return on Investment to the Practice)
Stage 5: Scaling and Sustaining CMM
Aim 5: Accelerating Spread and Adoption of CMM in Primary Care